You can get more details about what this plan covers in this brochure (PDF).

In- and out-of-network dental benefits

When you go to a dentist in this plan's preferred network, that's called getting your care in network. Find a dentist.

Because this plan is a PPO, it shares the cost if you go to a dentist that isn't in the preferred network. That's called getting your care out of network. You'll save money if you use a preferred network dentist.

Your deductible

You pay one deductible for Class II and Class III dental services.

  • One member on the plan: $25 in network, $50 out of network
  • Two members: $50 in network, $100 out of network
  • Three or more members: $75 in network, $150 out of network

Dental benefits for pediatric members

Dental benefits for pediatric members work differently than they do for adults. For example, there's no waiting period on services. And when you see a dentist in the preferred network, there's a limit on your share of the costs. That's called an out-of-pocket max. Children can get pediatric dental benefits until the end of the calendar year in which they turn 19. In a year, you pay:

  • No more than $350 total for one pediatric member
  • No more than $700 total for two or more pediatric members
What we call it What it is When you pay
What you pay
Class I

Preventive services like:

  • Exams
  • Cleaning
  • Bitewing X-rays
In network
Before out-of-pocket max
20%
After out-of-pocket max $0
Out of network
Any time
50%
Class II

Minor restorative services like:

  • Fillings
  • Root canal treatment
  • Other X-rays

In network
Before out-of-pocket max Your deductible, then 50%
After out-of-pocket max $0
Out of network
Any time
Your deductible, then 50%
Class III

Major restorative services like:

  • Crowns
  • Oral surgery
  • Gum surgery

 

In network
Before out-of-pocket max Your deductible, then 50%
After out-of-pocket max $0
Out of network
Any time
Your deductible, then 50%